Public Health Dental Hygiene Dental (PHDHP) Survey

I. DEMOGRAPHICS

* 1. Location of personal residence (zip code)

* 2. Location of primary practice site (zip code)

* 3. Do you currently hold a PHDHP license?

YES

NO

* 4. If answered YES to Question #3, list license number and date issued:

* 5. Are you eligible for PHDHP licensure?

YES

NO

NOT SURE

* 6. Do you currently hold a Local Anesthesia license?

YES

NO

* 7. If answered YES to Question #6, list license number and date issued:

* 8. Are you currently a School Certified Dental Hygienist?

YES

NO

* 9. Are you currently a Member of the ADHA?

YES

NO